Bringing Excellence To Substance Abuse Services in Rural And Frontier America
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Angeline Bushy, Ph.D., R.N., C.N.S.
Professor—Bert Fish Endowed Chair
School of Nursing
University of Central Florida
Daytona Beach, Florida
| Abstract
This article describes the rural health care delivery system, particularly as it has an impact on those who need mental health and substance abuse services. The concepts of availability, accessibility, and acceptability of health care are examined in relation to traditional rural belief systems described in the literature. Professional opportunities and challenges are highlighted. Strategies are included that can enhance the continuum of care for clients who live in regions with sparse resources. The content is based on a review of the literature, the author's many years of personal and professional rural experiences, and verbal reports from professionals who practice in a variety of rural health care settings. The discussion is intended to create awareness about and sensitivity to the special concerns of rural clients who need mental health and substance abuse services. |
Federal policymakers are proposing major cuts in the budgets for mental health and substance abuse and are also proposing major changes and reductions in the Medicaid program. The Medicaid program will probably be restructured with greater State-based control. To address concerns stemming from these proposals, mental health and substance abuse professionals met at a 1995 conference, "Partners for Change," designed to bring these professionals together with policymakers. By the end of the conference, the country's mental health planning directors, alcohol and substance abuse directors, and State Medicaid directors had formally agreed to an unprecedented collaboration that would be fostered by the Federal Government (APHA 1995). This stance is a major shift from the past pattern in which mental health and substance abuse strategies were dealt with separately and often unequally. The approach is logical, because some individuals have both mental health and substance abuse problems, and many who seek help for medical problems also have emotional problems. It was recognized at the conference that partnerships between private providers and all levels of government are necessary to effectively use diminishing resources. As the health system shifts to managed care and contracts are mandating more out-of-hospital interventions, quality care for mental health and substance abuse may be even more difficult to obtain. It is hoped that the new trend will lead to treatment for mental health and substance abuse as part of primary care.
Rural residents are faced with some rather unusual concerns when seeking mental health and substance abuse services in a reformed system. There is, however, no "common" culture for rural residents. Every rural community is unique, with its own underrepresented groups, economic and social structures, health problems, resources, and patterns of caring for members in need. Stemming from similar geographical and population factors, sociologists concur that living in small towns or in a sparsely populated area creates some unique experiences for residents as opposed to living in a more populated area. These variations and their impact on mental health and substance abuse services will be examined (Lee 1991; Rogers and Burdge 1985; NIMH 1986, 1989, 1990; Wagenfeld et al. 1994; USDHHS 1986).
Often cited themes in the literature reflecting traditional rural preferences are subjugation to nature, fatalism, and an orientation to concrete places and things (Flax et al. 1979; Wagenfeld 1982). Ruralites are believed to be more politically conservative, have stronger religious preferences, have a work ethic, be less tolerant of nontraditional beliefs, and have a preference for primary relationships (kith and kin). Compared with an urban lifestyle, the typical rural lifestyle is characterized by greater spatial distances between people and services; an economic orientation related to the land and nature (agriculture, mining, lumbering, fishing); work and recreational activities that are cyclic and seasonal in nature; and social interactions that facilitate informal (face-to-face) negotiations. In essence, small towns are the center of trade while churches and schools are the center of social activities for localities (Bergland 1988; Brown et al. 1994; Mellon 1994; Neese and Fox 1994; Stein 1989; U.S. Office of Technology Assessment 1990).
Self-reliance, which includes self-care behaviors, is another characteristic attributed to rural residents. Historically, self-care skills helped people to survive in austere, isolated, and rugged environments. This is reflected in the statement, "We take care of our own," from which we can infer a preference for receiving care from familiar people. Neighborliness and close-knit families can be beneficial in eliciting health promotion and compliance behaviors. In other cases, the members in these groups become enmeshed, resulting in a closed system. For instance, while a close-knit family can be highly supportive to someone with an emotional or substance abuse problem, in other cases, the family can hinder a sick person from seeking outside help. An overly solicitous family also can develop a high tolerance or immunity to the dysfunctional behavior exhibited by a family member. In these situations, the impaired person comes to be viewed as normal, as others in the family do not notice as odd, idiosyncratic behaviors progress to pathology (Bushy 1994; Johnson 1994; Taylor 1982; Weinert and Long 1991.)
As with a family, dysfunctional interpersonal dynamics also can occur in close-knit rural communities. For instance, residents in a small town may develop a tolerance toward certain lifestyle activities, especially in regard to consumption of alcohol, sexual practices, and corporal punishment. Mental illness and substance abuse, too, may come to be viewed by a community as a family's weakness (a skeleton in the closet). Secrecy is reinforced by the rule of silence: "What happens in the family—stays in the family." This adage is of particular significance in rural communities, where most of the local families have lived and worked together for generations. In order to maintain the integrity of the family, it becomes important not to let everybody in town know about sensitive family issues, in particular, substance abuse, domestic violence, incest, or mental illness (Murray and Keller 1991).
Consider the case of Joe, a client who lives in a remote southern town with less than 800 residents. Recently, Joe was diagnosed with a bipolar disorder. While providing family history, he tells the outreach counselor, "I heard some local people say that Uncle Tom, Great Grandpa, and a cousin drank a lot, were big spenders, and tore up the town every now and then. They all spent time at the State hospital, too, but our family never talks about that. Friends say my mental health problem is a family weakness." These remarks illustrate how familiarity among local residents, limited professional services, and lack of education perpetuate the stigma associated with mental illness and substance abuse.
How a group defines health and illness also is culturally based and can influence health care-seeking behaviors. For example, some rural people define health as the ability to work; to do what needs to be done. One can infer that, for them, illness probably means not being able to do one's usual work. The association between work, health, and illness reinforces the rural work ethic and dictates choice of leisure activities. As for mental illness and substance abuse, a family may continue to deny one of its member's emotional problems as long as he or she is able to complete assigned work activities. Over time, the expectations for the affected person are modified to accommodate declining abilities and the family's perception of the disability (Bushy 1994; Flax et al. 1979; Wagenfeld et al. 1994).
Consider the case of 31-year-old Brian. The townsfolk say he is strange and sees things that aren't real. His mother disagrees with them. She says, "How can people talk about him that way? He always helps Dad with the farm work. Oh, he drinks a little when he gets to a bar but, he only goes into town once in a while à never had much interest in girls and always was different than my other five children à he's more religious and dependable. Dad says most days he does a really good job with the outside work!" Obviously, the work ethic colors these parents' perception of Joe. More than likely, Joe's ability to complete work assignments also will be a consideration if Joe seeks professional treatment.
A work ethic can be attributed in part to being dependent on small, family enterprises, another characteristic of rural environments. Small businesses, such as farming, ranching, grocery stores, and service stations, however, often do not provide employee benefits, in particular health insurance. Economic structures have perpetuated the number of working poor in rural communities. Other activities that may be delegated a secondary position to work by rural residents include:
In brief, the individual's needs may be relegated secondary to the family enterprise, which may be their primary source of income.
Generally the incidence of mental health and substance abuse problems in rural areas is reflected as "treated prevalence," that is, the number(s) of clients who actually use a service. Some reports suggest a higher incidence of depression, alcohol abuse, domestic violence, incest, and child neglect in rural populations.
These reports can be partly attributed to the economic woes confronting many agriculture-based communities, which create family and community stress. The term "farm stress" reflects the emotional response to economic circumstances evidenced by the rising incidence of suicides and accidents resulting in injury and death, especially in adolescent males and adult men (Wagenfeld et al. 1994; Wagenfeld and Wagenfeld 1990).
Beyond those reports, estimates on the prevalence of mental health and substance abuse problems in rural populations for the most part are just that—estimates. They are based on word-of-mouth reports by professionals who represent an urban-based agency that provides outreach services to rural communities in its catchment area. These estimates probably are even less reliable if one considers that services to treat clients with mental health and substance abuse problems are not even available or accessible to those who may desperately need it. The problem is even more ambiguous when examining rural residents' utilization patterns of social support systems.
The first level of social support includes the services that are volunteered by family and friends, for which there is no remuneration. Often there is an unwritten code of reciprocity among participants in this informal system.
The second level includes the services provided by community groups, such as church, school, and civic organizations (e.g., homemakers' clubs, church circles, fraternities, the Chamber of Commerce). Group members collaborate to provide assistance to needy individuals and families within the community. Examples of reciprocal helping activities include volunteering time, services, food, and other nonmonetary items as well as contributing financially to those in need. Donating in-kind services offers a kind of "insurance policy" should a catastrophic event occur in a volunteer's family system.
The third level of support consists of formal services, sponsored by governmental agencies and/or private industry. Financial remuneration is expected for the services provided, albeit often on a fee-based-on-income.
In comparison with urban residents, rural residents have historically relied on the two informal levels of social support, thereby enhancing their self-reliance. Recent demographic and social changes in some rural regions have disrupted natural helping systems, forcing rural residents to rely more on the third level of social services. Yet critically needed mental health and substance abuse services often are not available, accessible, or acceptable to rural communities.
"Availability" refers to the existence of and the necessary personnel to provide a service. Economically, the sparseness of population limits the number and array of human/health care services in a given region. The per-capita cost of providing special services to a few people often becomes prohibitive, particularly in frontier regions. Moreover, almost 40 percent of the mental health and substance abuse personnel are hospital based in rural areas, as opposed to 18 percent for the country as a whole. Consequently, the availability of mental health and substance abuse services is dependent on the stability of rural hospitals, many of which are in tenuous financial situations and are on the verge of closing. Specialists, too, tend to be concentrated in urban environments. Overall, physicians and other types of health care and human service providers are fewer in rural areas. Especially lacking are health personnel with advanced education, in particular in the areas of mental health and substance abuse. Hence the Federal designation of Health Professional Shortage Areas (HPSAs) describes regions that are significantly underserved (Wagenfeld et al. 1994).
The availability of mental health and substance abuse professionals, and their services, also is influenced by educational programs. Most professional schools are located in urban areas, giving students limited exposure to rural practice. On completion of their educational programs, health and human service professionals have a preference for urban employment. This preference can be partially attributed to being educated in an urban specialty bias, as opposed to being educated as a generalist, the latter being better suited for rural practice.
Where mental health and substance abuse services and personnel are scarce, the existing ones must be prudently allocated. To address the professional shortages, rural providers often are expected to assume multiple roles in order to function in a variety of situations. For example, in one practice setting, a counselor in a mental health clinic may need to function in the roles of case manager, grant writer, crisis worker, administrator, public relations person, and therapist. Additionally, several times a month this person may be scheduled to provide outreach services to schools and senior citizen facilities that are located in various towns in the multicounty mental health district. This also is the case for rural addiction counselors who must provide a range of services in a large geographical area (Fuszard et al. 1991; Parker et al. 1991).
"Accessibility" refers to whether a person has access to, as well as the ability to purchase, needed services. Accessibility to mental health and substance abuse services by rural clients is impaired by a variety of factors, including great distances that must be traveled to obtain services, lack of public transportation, lack of telephone services, insufficient numbers of providers to provide outreach services, inequitable reimbursement policies, unpredictable weather conditions, and the inability to procure entitlements to obtain needed services. Furthermore, rural people who experience human service needs frequently are less able to be an advocate on their own behalf. They may be limited by physical or emotional disabilities or even lack the sophistication to access a complex system (Wagenfeld and Wagenfeld 1990; Weiler and Buckwalter 1994).
Access to public and private funding sources to implement needed programs also can be hampered by a lack of grantsmanship skills on the part of rural providers. Successful grant writing evolves with practice and requires dedicated time on the part of a writer to produce a fundable project. Those prerequisites, however, may not be realistic expectations for providers in professionally underserved regions, as they often are overextended with excessively large client caseloads. Additionally, they may not have access to continuing education (CE) programs that disseminate current information on grant writing (Human and Wasum 1991).
Rural political structures, too, may resist outside help. Resistance frequently is evidenced by leaders in a community not providing support for a grant proposal to procure funding for a special program. Interestingly, the political power in rural communities often is vested in an elite portion of the local population. These individuals frequently are unaware of the needs of local underprivileged groups. Consequently, powerless racial and ethnic minorities may have human service requirements to which the more affluent and powerful majority in rural communities are not sensitive or sympathetic. Their behavior reflects traditional rural values related to the work ethic and the stigma associated with seeking public assistance for a personal or financial problem. Consequently, rural people needing human services may not seek, or accept, even those programs that are available and accessible to them (Wagenfeld et al. 1994).
"Acceptability" refers to whether or not a particular service is offered in a manner that is congruent with the values of a target population. Considering the diversity among rural people, acceptability of mental health and substance abuse services can be hampered by the following factors: traditions of handling personal problems (self-care practices); beliefs about the cause of a disorder and the appropriate healer for it; and lack of knowledge about emotional disorders and the place of formal services in treating the condition.
Acceptability of services by rural groups also is influenced by the urban orientation of health professionals. A provider's attitude toward rural practice can perpetuate difficulties in relating to the rural environment as well as to the people living there. Insensitivity also can exacerbate rural clients' mistrust of mental health and substance abuse professionals who provide community outreach. Thus, residents may perceive outreach providers as community outsiders, which can perpetuate feelings of professional isolation and nonacceptance.
To ensure that a program is acceptable by the target community, a community assessment should be done prior to planning and implementing a new program. The use of culturally relevant data can help to ensure that services are provided in a manner deemed appropriate by the target population (Bushy 1994; Wagenfeld et al. 1994). When planning a new mental health and substance abuse program, for example, providers should consider the target population's perceptions about:
In brief, consideration of personal and environmental factors can go a long way to enhance the continuum of care for rural clients.
The problem of recruiting and retaining health professionals in rural areas also affects planning and implementing mental health and substance abuse programs. The following discussion summarizes factors that have an impact on rural professional practice. These factors can be seen as opportunities and/or challenges by rural professionals who provide mental health and substance abuse services. It is important to emphasize that, as with practice in an urban setting, one will view a particular rural factor (deterrent) as extremely negative, while another perceives that same factor to be a challenge (opportunity) that can be resolved via one's creative abilities.
Living in a rural environment offers a lifestyle that some professionals find very appealing. Depending on the geographical area, the benefits include rearing children in a smaller community, a lower cost of living, outdoor recreational opportunities such as skiing, fishing, hunting, and hiking, a slower paced lifestyle, less crime, not having to commute great distances in heavy traffic, less air pollution, personally knowing your neighbors and clients, and personal and professional visibility that lends itself to making a difference in the community's health care system.
One common characteristic that has a significant impact on the recruitment and retention of mental health and substance abuse professionals is the geographical remoteness of a rural community. How remoteness is perceived, however, depends upon one's life experiences. For instance, residents in frontier States such as Utah, Montana, Idaho, North Dakota, New Mexico, and Alaska do not view remoteness from the same perspective as those living in California, New York, Ohio, or Florida. Likewise, one person may describe rural residency as "living in isolation," while another views it as "personal solitude." Even so, the most frequent complaint of rural providers is the professional isolation they experience, especially the lack of available peer support and access to continuing education. Professional isolation poses a particular challenge for health professionals with advanced education in mental health and substance abuse, as the need to function as a generalist can result in forgetting specialty skills. Since salaries in rural areas often are lower than in urban settings, some may say that the compensation is not adequate for an advanced practice (Bushy 1994).
Despite the apparent obstacles, many rural professionals have creatively established network/support systems that are as reliable as those that may be in closer proximity. Additionally, there is a national trend for universities and professional schools to provide peer support, consultation services, and off-campus (outreach) courses via the electronic media to rural providers. Collaborative efforts between educational institutions and health care agencies are helping to alleviate the problem of professional isolation in some remote communities. Technology is rapidly evolving, and we can expect to have more continuing education offerings using those strategies.
News travels quickly through a small community because there are fewer people, many of whom are acquainted. Most small towns have an active local grapevine that includes information about the community's sick (especially those with an emotional problem) as well as their experiences with the health care system. These informal networks can offer important support to the impaired and yet interfere with maintaining professional/client confidentiality and anonymity. It is not unusual for confidentiality issues to arise because of the location of the mental health and substance abuse clinic. When a clinic is located in a highly visible area of the town, passers-by will note whose car is parked in front of the building and who goes in and out of the building. For these reasons, careful consideration should be given to the best location for a mental health and substance abuse clinic, as it is not unusual for local residents to recognize other community members by the kind of car(s) they drive. It may be prudent to place the clinic within a building that houses another medical or dental clinic, hospital, social services, or general office building.
Once a professional has gained entrance to and is accepted by a community, practice problems can arise from being widely recognized by local residents. Because of the visibility, it is difficult to have some degree of privacy and to get away from work. Clients, or someone in their family may recognize—acknowledge—and then stop to chat with "my counselor." This degree of familiarity accommodates rural people's preference for informal communication patterns. A client may not think it unusual to telephone a caregiver's home or discuss a personal concern with a professional in a public place, such as a grocery store, service station, or at church, school, or community functions.
Effective ways to prevent such events are through public education on what constitutes a crisis, the process to be followed should an untoward event occur, and learning to tactfully evade those situations and bringing up another subject of mutual interest.
It is not overstating the case to say that rural professionals should be generalists, as opposed to being specialists. Health professionals caring for rural client systems are expected to work with all age groups that have a myriad of problems. They must, however, be aware of formal and informal resources in order to provide a continuum of care to clients needing mental health and substance abuse services.
Acceptance by a community and patient satisfaction, combined with health professional shortages, results in rural providers having extremely large client caseloads. On occasion, a physician, nurse, or counselor may be on call around the clock for weeks or months. Being on call does not necessarily mean that one will be called or actually see a client. It does mean, though, that the person on call is restricted to the community in the event he or she is called. Obviously, one can become burned out by unremitting professional demands if limits are not set. Therefore, when first establishing a practice in an underserved area, it is important to identify someone who is willing to provide backup coverage to reduce the risk of burnout.
Considering the inequitable distribution of services and providers, the following strategies can facilitate providing a continuum of care for clients living in rural areas by integrating formal with informal resources.
To reiterate the position statements from the "Partners For Change" conference in mental health and substance abuse, resources are limited and therefore should be prudently used, especially in rural areas. Interdisciplinary collaboration is critical to reduce turf issues between providers within a given region. Each provider must assume personal responsibility to be knowledgeable of available resources and be able to make appropriate referrals in order to implement a seamless continuum of care for clients needing mental health and substance abuse services.
Urban professionals often are not familiar with mental health and substance abuse services that are available in the rural catchment areas. For that matter, neither are many of the professionals who live in outlying communities.
To address this deficit, the rural health professional can compile and disseminate information on available services and resources, using the following guidelines: List formal agencies and institutions as well as informal organizations. Include all of the services, names of providers, credentials, addresses, telephone numbers, and hours of service. Be sure to include emergency listings. This listing should be disseminated to both rural and urban professionals to assist them in appropriate discharge planning for rural clients (Parker et al. 1991; Tierney and Baisden 1990).
Case management can help to avoid duplication of services, facilitate interdisciplinary collaboration, and integrate formal with informal services that are tailored for a client. Case management is particularly well suited for environments having fewer resources, professional shortages, and restricted access to services—characteristics of many rural communities. This model meshes nicely with a rural preference of having a personal acquaintance involved in administering care to one in need.
All clients should be actively involved in their discharge planning, which includes anticipating and planning for potential adverse events. Potential problems for rural clients can arise from unavailable or inaccessible services, for example from a pharmacist, dietician, physical therapist, occupational therapist, psychiatrist, or social worker. It is prudent for mental health and substance abuse professionals to negotiate a contingency plan (contract) that clearly states what the client will agree to follow should events go awry or a crisis occur. An individual who generally is available to the client should be specified. In some cases, a second person (backup) may be needed should the first one be unavailable. Examples of potential backups include the sheriff, a clergy member, a fellow church member, a county nurse, a dependable neighbor, or extended family. Situations to consider include whether or not telephone service is available in the home, lack of access to a crisis line, no available mental health and substance abuse professionals (for example, the town has outreach services only every other Monday), restricted access to a pharmacy to get a prescription filled, and limited laboratory services to monitor medication levels (Bushy 1994).
Clients who are placed on medication always need careful and ongoing education about their pharmacotherapy regimen. Rural clients may require additional considerations related to restricted access to pharmacy services. For instance, seriously depressed persons having a potential for self-harm usually are dispensed a carefully controlled supply of medication to reduce the risk of overdosing. In rural environments, logistical barriers, such as not having access to transportation or the need to travel a great distance to the nearest pharmacy, may result in a client needing a greater number than usual of doses of medication dispensed directly to them. For the purpose of risk management, identify a responsible individual who sees the client on a regular basis. (Obviously, he or she must be informed of the responsibilities and expectations and agree to be involved in the contingency plan.) This person should be taught to monitor a client's medication practices, safely secure extra doses, then issue a specified amount at designated intervals.
Noncompliance behaviors also should be discussed and planned for. It is not unusual for a client to feel good after taking medication for a period of time. If family members are not informed about this phenomenon they, too, may believe the client is back to normal, especially if they cannot afford the prescription. In the contingency plan, identify situations and events that preempt the client's reluctance to take medications or not adhering to the prescribed dosage. Verbally instruct and then clearly write the effective interventions to alleviate medication side effects. For some clients, it may be effective to list behaviors that occur with noncompliance, such as hearing voices, drinking alone, threatening or frightening family, or wanting to harm self or others. Include a procedure to follow if the client does not keep an appointment—for instance, contact a certain neighbor, minister, sheriff, or personally visit the client's home. The contingency plan should be written explicitly and then explained (interpreted) by the client in his or her words. It should be trial-tested. Role play all of the options and involve all in the plan.
In planning and scheduling followup care, consider the client's lifestyle and home situation, particularly for those living some distance from the provider. Before scheduling a followup appointment, anticipate why a client might not keep it. For example, the major industries and family activities in rural areas often involve seasonal work (haying, planting, harvesting, calving), routine daily activities (feeding animals, milking cows, transporting children to and from school, preparing meals for hired help), and environmental uncertainties that can impair travel (icy roads, snow storms, mud slides). If at all possible, accommodate those responsibilities.
Education about mental health and substance abuse symptoms and interventions is particularly lacking in the general population. Health professionals in general and mental health and substance abuse providers in particular have a responsibility to educate the community as a whole on those topics. An effective strategy to disseminate information to target groups is by collaborating with existing and accepted community organizations. Many rural families traditionally obtained health information through the female head of household. Homemakers and church circles historically included a health component in meetings, and this was a family's principal source of health information. Other effective approaches to disseminate information are the local media, such as newspapers, church bulletins, public service programs on radio and television as well as organizational newsletters (for example, Farmers Union, Farm Bureau, WIFE, the County Extension Agent's office). Posting information at collective meeting places in a small town—for example, on bulletin boards located in restaurants, grocery stores, bars, the county court house, and grain elevators—is another way to inform the public of mental health and substance abuse programs.
Materials should be prepared at an appropriate reading level and presented in language that is culturally acceptable and meaningful to the target audience. Be especially sensitive to the high number of individuals who may be functionally illiterate (reading below the fifth grade level) and have English as their second language.
Programs offering continuing education also may be unavailable to rural professionals; those that are provided may not be relevant to rural practice. Since mental health and substance abuse clinics often are part of a larger network (State and Federal Agencies), this affiliation can facilitate bringing an outside speaker to a community for a continuing education program. For instance, consultants from the State mental health and substance abuse department will be knowledgeable about current psychiatric pharmacotherapies, State/regional services, and grant writing. Other topics on mental health and substance abuse that are in demand by professionals include:
In brief, professional-community partnerships are critical to effectively use limited resources! Administrators of mental health and
substance abuse programs should initiate and encourage student clinical rural experiences with institutions of higher learning. Ultimately, exposure should result in a greater number of graduates electing to work in rural practice.
Rural health professionals have high community visibility and are in positions to influence change and establish partnerships. The rural health professional should develop the skills to speak to a variety of groups and individuals, including other professionals, consumers, and policymakers. Elected officials, too, are interested in policies having an impact on mental health and substance abuse programs and their rural constituencies. Inform lawmakers about local needs and offer suggestions to assist them in making better informed policy decisions on mental health and substance abuse in their district. In this era of shrinking budgets and shifts in political power, partnerships are needed at all levels to effectively address the mental health and substance abuse needs of the U.S. population as a whole, and rural residents in particular.
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